MyHealthGuide Newsletter News for the Self-Funded Community 8/3/2020
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TABLE OF CONTENTS
General & Company News
Medxoom Releases Universal Engagement and Payments Platform for TPAs HCAA's TPA Summit 2020 Was a Virtual Experience to Remember for 671 Registrants The Phia Group Announces Webinar: Conflicts Abound – Providers & Facilities Fight Back Healthcare Transformation Consortium Named a 2020 Health Value Award Winner by Validation Institute Employer Direct Healthcare Announces Partnership With AFGlobal Corporation
People News
The Phia Group Announces Promotion of Jason Davis to Senior Vice-President of Provider Relations MacroHealth Makes Key Investments in Executive Talent: Steve Suter, Matt Thorne and Sam Crumley Tokio Marine HCC - Stop Loss Group Introduces Christine Carlson as Senior Vice President of Claims NHSI Appoints Jesse “Jay” Beck as New Executive Vice President
Market Trends, Studies, Books & Opinions
In-Network Hospital Surgeries Sometimes have Out-of-Network Surgical Assistants Adding to Medical Bills and Possible Balance Billing to Patients Study Reviews SARS-CoV-2 Screening Strategies to Permit the Safe Reopening of College Campuses
Legislative News
Third Circuit: Provider’s Out-of-Network Claims not Pre-empted by ERISA
Medical News
Antibiotic Therapy has 61% Success Rate vs Laparoscopic Appendectomy Among Children With Uncomplicated Appendicitis
Recurring Resource Links
Medical Stop-Loss Providers Ranked by 2019 Annual Premium Tops $23 Billion (updated: 5/23/2020) ICD-10 stop-loss Trigger Diagnosis Tools The Value of Self-Funding An Introduction to Self-Funding: What, Who & How
Upcoming Conferences
Job News (Listings are generally published for 1 month)
Berkley Accident and Health Seeks a Group Captive Program Manager Responsibilities CWI Benefits in Greenville, SC Seeks Vice President of Operations Professional Benefit Administrators, Inc. (PBA) Seeks Claims Manager Berkshire Hathaway Specialty Insurance Company Seeks Experienced Senior Underwriter HM Insurance Group Seeks Senior Medical Stop Loss Underwriter FullscopeRMS Seeks Two Positions The Phia Group Open Positions MSL Captive Solutions Seeks Senior Underwriting Specialist and Senior Administrative Specialist
Editorial Notes, Disclaimers & Disclosures
General & Company News
Medxoom Releases Universal Engagement and Payments Platform for TPAs
MyHealthGuide Source: Medxoom, 7/17/2020
ATLANTA -- Medxoom, the Atlanta-based B2B Health Benefits Platform, announced the release of a comprehensive Payments suite for TPAs and other Healthcare Payers.
Medxoom’s Payments platform closes the gap between Healthcare Plan Members and Providers. Medxoom licenses its brandable platform to Healthcare Plans and Benefit Administrators, offering a unified member engagement experience, tying all plan components and payments into a single unified experience.
“Healthcare Plan-to-Provider Payments have been a fragmented, asynchronous patchwork of processes that include eligibility determination, pre-authorization, claims adjudication, slow and costly remittances, and finally billing patients for net due amounts for decades,” says Jeff Toewe, Medxoom CEO. “Legacy healthcare payments processors are just getting around to ACH vs. paper checks now. Yet the fundamental disconnect between Plan, Member and Provider still persists. Medxoom closes this gap; we engage Healthcare Plan Members directly, in real-time, enabling them to discover Healthcare services, offering a clear picture of their price and payment options for these services.”
“Plans using Medxoom PricePoint and Medxoom SPC can offer Members the ability to discover prices and also a real-time, paid-in-full experience for common Healthcare services. We’ve eliminated the very fragmented and months-long processes of pre-authorization, claims adjudication, remittances, and patient responsibility collection. Sending real time paid in full Members to Providers also eliminates the need for Providers to chase Patients for net due balances, driving more favorable price offerings.”
“We’re pleased to be supporting the modernization of the Healthcare Payments experience. It’s a big market, and it’s long overdue. All constituents in the Healthcare ecosystem deserve more streamlined payments,” says Dean Hatton, Partner at Las Olas Venture Capital.
Medxoom’s platform helps Healthcare Plans and Benefit Administrators to offer a fully modern member experience with multiple features to help drive cost savings, including PricePoint cost discovery, integrated Telehealth, Concierge and Payments modules. Health Plans and TPAs can effectively respond to the “Amazon effect,” wherein Consumers demand usability, clarity and efficiency in their shopping experience, delighting Members with a best of breed mobile and web experience.
“Combining price discovery and streamlining payments via frictionless methods is key to cost containment in the US Healthcare system. It’s the next logical step in powering a more transparent, efficient marketplace model and we are happy that our customers are embracing this enthusiastically,” says Shankha Basu, Medxoom COO and lead Data Scientist. “We’re driving measurable savings for all players in Healthcare.”
About Medxoom
Medxoom powers Modern Healthcare Marketplaces. Medxoom licenses a comprehensive white label engagement and payments platform to healthcare plans and benefits administrators. Medxoom unifies the health benefits experience. We make it easy for Members to navigate their benefits to make better healthcare choices - saving time, money and hassles. Contact John Glascott, CCO, at [email protected], 914.373.1437 and visit medxoom.com.
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HCAA's TPA Summit 2020 Was a Virtual Experience to Remember for 671 Registrants
MyHealthGuide Source: The Health Care Administrators Association (HCAA), 7/29/2020
The 2020 HCAA Virtual TPA Summit was certainly one we will remember forever! As our first virtual HCAA event, we couldn’t be more pleased with how the program ran. Attendees and HCAA members can always access the conference speaker videos and presentations on the Past TPA Summit Materials page of the website.
HCAA wants to thank the 671 registrants and dedicated sponsors for making this event possible, and the countless hours the HCAA staff and committees put in behind the scenes to navigate how to pull this off in a short timeframe. We couldn’t have made this the engaging event that it was without the support from all of you!
We hope that you consider joining us next summer for the 2021 TPA Summit from July 19-21 in Dallas as the Hyatt Regency Dallas! And we look forward to bringing more powerful speakers, interactive exhibit halls, and networking activities to our HCAA membership in the future as a way to further the connection whether that be in person in Dallas or virtually.
About HCAA
The Health Care Administrators Association is the nation’s most prominent nonprofit trade association supporting the education, networking, resource and advocacy needs of benefit administrators (TPAs), stop loss insurance carriers, managing general underwriters, audit firms, medical managers, technology organizations, pharmacy benefit managers, brokers/agents, human resource managers, plan sponsors and health care consultants. For almost 40 years, HCAA has taken a leadership role in transforming the self-funding industry, and increasing the importance of self-funding as an important alternative in the health care delivery systems of our country. Visit www.HCAA.org.
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The Phia Group Announces Webinar: Conflicts Abound – Providers & Facilities Fight Back
MyHealthGuide Source: The Phia Group, 7/31/2020
Webinar Title: Conflicts Abound – Providers & Facilities Fight Back
Description: U.S. hospitals have lost over $200 billion from March to June as a result of canceled services due to the COVID-19 pandemic. In response, providers have changed their tactics. They are raising prices, appealing more denied claims, more aggressively fighting referenced-based pricing, and stepping up collections efforts. Now, more than ever, it is imperative for plans and their partners to be vigilant and protect their members and plan assets. Join The Phia Group’s team on Tuesday, August 18th at 1 p.m. EST as they discuss these new aggressive tactics as well as the conflicts they are causing with networks and stop-loss. Webinar Link.
About The Phia Group
The Phia Group, LLC, headquartered in Canton, Massachusetts, is an experienced provider of health care cost containment techniques offering comprehensive services, designed to control health care costs and protect plan assets. By providing industry leading consultation, plan drafting, subrogation and other cost containment solutions, The Phia Group is truly Empowering Plans. Visit www.PhiaGroup.com.
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Healthcare Transformation Consortium Named a 2020 Health Value Award Winner by Validation Institute
MyHealthGuide Source: Hunterdon Medical Center via TapInto, 7/31/2020
The Healthcare Transformation Consortium (HTC) has been named a Health Value Award winner by Validation Institute for their 2020 awards program in its non-peer-reviewed category for Healthcare Purchasing Collaborative.
The members of the collaborative, each with self-funded employee health plans, work together to address a growing challenge faced by businesses across the state: how to ensure high-quality health care for their team members while reducing the overall cost of providing health insurance and delivering care.
Winners were announced earlier this year in a virtual ceremony that recognized healthcare leaders and innovative vendors across the country. Now in its third year, the Health Value Awards continues to recognize outstanding services, products, and programs across 30+ categories spanning the healthcare industry.
The HTC is a collaborative of health care organizations that includes Atlantic Health System, CentraState Healthcare System, Holy Name Medical Center, Hunterdon Healthcare, St. Joseph’s Health, Saint Peter’s Healthcare System and Virtua Health.
“The Healthcare Transformation Consortium is committed to collaborating with our member health systems to create an innovative new model for health care delivery for New Jersey, so we are honored to be recognized by the Validation Institute,” said Kevin Joyce, Vice President of Insurance Networks for Atlantic Health System. “By working closely with like-minded organizations, we are able to share best practices, and lead the transition from fee-for-service to value-based care while providing the highest quality care for our dedicated caregivers and their families.”
“Now, more than ever, we are seeing the importance and strength and dedication of healthcare workers in our country. While we were unable to celebrate our finalists in person, we feel it was important to host this event virtually, celebrate these leaders and recognize all they do for the industry,” said RD Whitney, CEO of Validation Institute.
Health Value Award candidates complete a lengthy and rigorous application process, particularly those nominated in a peer review category who participate in an in-depth evaluation to ensure the accuracy of performance claims.
About the Healthcare Transformation Consortium
The Healthcare Transformation Consortium (HTC) is a collaborative of leading, independent health systems based in New Jersey, each with self-funded employee health plans, that share their expertise to address issues many businesses now face: how to improve access to high-quality health care for covered employees and dependents while reducing costs. Members of the consortium include Atlantic Health System, CentraState Healthcare System, Holy Name Medical Center, Hunterdon Healthcare, St. Joseph’s Health, Virtua Health and Saint Peter’s Healthcare System. Visit htconsortium.com.
About the Validation Institute
Validation Institute is a membership organization made up of a network of healthcare vendors, health benefits advisors, and purchaser benefit managers focused on delivering better health value and stronger outcomes than conventional healthcare. Visit www.validationinstitute.com.
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Employer Direct Healthcare Announces Partnership With AFGlobal Corporation
MyHealthGuide Source: Employer Direct Healthcare via PRNewswire, 7/29/2020
DALLAS -- Employer Direct Healthcare is excited to announce its recent partnership with AFGlobal Corporation. On January 1, 2020, AFGlobal began offering Employer Direct Healthcare's SurgeryPlus™ benefit, a supplemental benefit providing surgical concierge services with a focus on quality care, lower costs, and a better member experience.
Self-funded employers and their members participating in AFGlobal's health plan will have access to the SurgeryPlus™ benefit's full-service healthcare concierge for over 1,400 non-emergent procedures. When they choose to utilize the SurgeryPlus™ benefit, members will be paired with their own dedicated Care Advocate. Their Care Advocate will assist them with everything from their selection of a surgeon, to scheduling appointments, transferring medical records, and even arranging travel, removing the stress and confusion often associated with planning for medical care.
As an added benefit, when participants elect to use a participating surgeon through the SurgeryPlus™ benefit, AFGlobal will waive their out-of-pocket financial responsibility.
John Zutter, CEO of Employer Direct Healthcare, commented, "Our partnership with AFGlobal was formed earlier this year to help their employees, along with their families, access top-quality healthcare at fair prices. The current COVID-19 crisis has made this directive more critical than ever, and we are excited to continue to build on our strong momentum, driving savings and superior outcomes for our members."
About Employer Direct Healthcare and the SurgeryPlus™ Benefit
Employer Direct Healthcare is an innovative healthcare services business providing high-quality and cost-efficient solutions for self-funded employers and their members. The company's core product, the SurgeryPlus™ benefit, provides full-service surgical concierge services to covered members, managing the entire process on their behalf. The SurgeryPlus™ benefit helps members identify quality providers at lower costs, helping self-funded employers and their plan participants dramatically reduce surgical costs while providing satisfying outcomes for members. Employer Direct Healthcare is majority owned by Dundon Capital Partners, LLC, a Dallas-based private investment firm, founded by Tom Dundon. Call 855-200-2099 and visit edhc.com.
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People News
The Phia Group Announces Promotion of Jason Davis to Senior Vice-President of Provider Relations
MyHealthGuide Source: The Phia Group, LLC, 7/31/2020
Canton, MA - The Phia Group LLC, the health benefit industry's leading cost-containment service provider, announces the promotion of Jason C. Davis to the role of Senior Vice-President of Provider Relations.
"Jason has been partnered with The Phia Group for nearly 7 years, and we have grown tremendously during this time; we now want to highlight and reward his contributions with a seat at the executive table” stated Adam Russo, CEO of The Phia Group. “Jason has proven himself to me and our clients as a person of intelligence and integrity, and I believe he is the right person to lead our Provider Relations department to the next level."
Prior to partnering with The Phia Group in 2014, Jason Davis was Vice-President US Markets for Global Excel Management, where for nearly 10 years he contributed at various levels of claim settlement, dispute resolution, R&D, product development, sales, and leadership. “I believe in The Phia Group’s mission to lower healthcare costs for all, and so I am thrilled to be part of the Phia family and to build on our success,” added Jason Davis.
For more information regarding The Phia Group, please contact Vice President of Sales and Marketing, Tim Callender, by email at [email protected] or by phone at 781-535-5631.
About The Phia Group
The Phia Group, LLC, headquartered in Canton, Massachusetts, is an experienced provider of health care cost containment techniques offering comprehensive services, designed to control health care costs and protect plan assets. By providing industry leading consultation, plan drafting, subrogation and other cost containment solutions, The Phia Group is truly Empowering Plans. Visit www.PhiaGroup.com.
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MacroHealth Makes Key Investments in Executive Talent: Steve Suter, Matt Thorne and Sam Crumley
MyHealthGuide Source: MacroHealth, 7/30/2020
Kirkland, WA -- MacroHealth is thrilled to announce the addition of three Senior Executives to help scale their rapidly-expanding HCIT business. Steve Suter joins as Chief Operating Officer, Matt Thorne as Chief Financial Officer, and Sam Crumley as Chief Human Resources Officer.
Virgil Bretz, MacroHealth’s CEO commented, “There is massive interest in the healthcare marketplace to connect to our platform so it is an ideal time to have these amazing executives join our business. Steve has helped build and scale numerous service-based and HCIT businesses, Matt is deeply experienced at leading complex financial transactions in the healthcare arena, and Sam has played critical roles in growing SaaS-based businesses. Their collective talent and experience will be pivotal in helping MacroHealth disrupt the purchasing of healthcare.”
Suter, who currently serves as the head of SIIA’s Government Relations Committee, most recently served as President & CEO of Bellevue, WA-based TPA, Healthcare Management Administrators.
Thorne joins MacroHealth from telemedicine vendor, American Well, where he served as Vice President of Corporate Development.
Crumley joins the team from Panapto, a market leader in the creation and management of video content, where he served as the Vice President of Employee Experience and Head of HR.
About MacroHealth
MacroHealth’s purpose is to create Intelligent Health Markets™. We build relationships, knowledge and technology that enable payers and providers to optimize the buying and selling of health services. Contact Yong-Joo Hsiung at [email protected] and visit macrohealth.com.
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Tokio Marine HCC - Stop Loss Group Introduces Christine Carlson as Senior Vice President of Claims
MyHealthGuide Source: Tokio Marine HCC - Stop Loss Group (TMHCC), 7/29/2020
TMHCC, a leading provider of medical stop loss insurance, announced that Christine Carlson has accepted the position of Senior Vice President of Claims. Ms. Carlson brings to TMHCC over 15 years of industry experience in leading change management, optimization, innovation, customer experience, and team building.
Prior to joining TMHCC, Christine held a variety of claims operations leadership positions at Blue Cross and Blue Shield of Minnesota, most recently as a Senior Director.
Christine holds a Bachelor of Science degree in Business from the University of Wisconsin.
Jay Ritchie, President of TMHCC’s Stop Loss Group said “We are excited and confident that Christine will be a major contributor to our company’s success and an important part of our leadership team going forward.” Beata Madey, Executive Vice President, Stop Loss Group added that “TMHCC is well positioned to build upon our excellent customer experience and operational excellence by adding Christine’s leadership within our organization. ”
If you have any questions or need additional information, please contact Christine directly at (770) 693- 6582 or email her at [email protected].
About Tokio Marine HCC – Stop Loss Group
For more than 45 years, HCC Life Insurance Company, operating as Tokio Marine HCC – Stop Loss Group, has been leading the way in medical stop loss insurance for employers and plans who self-fund their benefit plans. Rated A++ (Superior) by A.M. Best Company, Tokio Marine HCC – Stop Loss Group is backed by the financial stability of its parent company, Tokio Marine HCC. Visit tmhcc.com.
Tokio Marine HCC – Stop Loss Group delivers competitive coverage through exceptional customer service. Our team of underwriters, claim specialists, actuaries and medical professionals provides personal service and professional expertise to a network of producers. Visit tmhcc.com/en- us/groups/stop-loss-group.
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NHSI Appoints Jesse “Jay” Beck as New Executive Vice President
MyHealthGuide Source: Assured Benefits Administrators (ABA), 7/31/2020
National Healthcare Solutions, Inc. (NHSI) is pleased to announce that Jesse “Jay” Beck has been appointed Executive Vice President of Growth & Strategy for three of its sister companies: Assured Benefits Administrators (ABA), Dallas Risk Management (DRM) and Independent Medical Systems (IMS).
Jay brings extensive experience, including roles as Vice President of Strategic Growth at Texas Health Resources, Director at Towers Watson, President & COO for Apex Global Partners and CEO of Century Health Care. He excelled in sales, marketing and leadership roles at UNUM, Canada Life Assurance Company and Mutual of Omaha. Jay co-founded Medical Home Exchange, a healthcare technology firm that was a precursor to the Direct Primary Care space.
“NHSI has ambitious growth plans for our domestic operations for both the short and long-term and we are confident that Jay will help us to achieve them,” said David Rendall, President and CEO of NHSI. “Jay Beck is a transformative leader who has made positive and meaningful changes to the healthcare arena.”
“I’m excited to join this dynamic group of companies,” said Jay. “ABA, DRM and IMS each have unique strengths and talented teams. My goal is to create a purpose-built collaboration that will bring meaningful value between internal and external partners.”
Jay holds a B.S. and an M.B.A. from Southern Methodist University, including completing a groundbreaking project on Medical Tourism in Cuba based on in-country research. He has served on the boards of the Dallas Children’s Museum and the Perot Museum of Nature and Science. Jay is currently a member of the Advisory Boards of Health Wildcatters, MediBookR and Cariloop.
About NHSI
National Healthcare Solutions, Inc. is the single source solution for all medical cost containment, case management, third party administration and PPO needs, whether in the U.S. or abroad. NHSI is independently owned and is part of an international healthcare group with more than 30 years of experience in the healthcare management industry. Visit nationalppo.com.
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Market Trends Studies, Books & Opinions
In-Network Hospital Surgeries Sometimes have Out-of-Network Surgical Assistants Adding to Medical Bills and Possible Balance Billing to Patients
MyHealthGuide Source: Markian Hawryluk, 7/29/2020, MedicalXpress (full text)
Excerpts below have been edited for brevity.
A meniscus repair operation was billed: $96,377 for the surgery by the hospital. It accepted a $3,216.60 payment from the insurance company, as well as $357.40 from the patient, as payment in full. The surgical assistant, an independent contractor, billed separately for $1,167.
The third-party surgical assistants who aren't part of a hospital staff or a surgeon's practice. They tend to stay out-of-network with health plans, either accepting what a health plan will pay them or billing the patient directly. That, in turn, is leading to many surprise bills.
Even before any other medical bills showed up, the patient can receive notice from someone not recognized. "I'm writing this letter as a courtesy to remind you of my presence during your surgery," the letter read from the surgery assistant. He went on to write that he had submitted a claim to her health plan requesting payment for his services, but that it was too early to know whether the plan would cover his fee.
Surgical assistants serve as an extra set of hands for surgeons, allowing them to concentrate on the technical aspects of the surgery. Oftentimes other surgeons or physician assistants—or, in teaching hospitals, medical residents or surgical fellows—fill that role at no extra charge. But some doctors rely on certified surgical assistants, who generally have an undergraduate science degree, complete a 12- to 24- month training program, and then pass a certification exam.
Surgeons generally decide when they need surgical assistants, although the Centers for Medicare & Medicaid Services maintains lists of procedures for which a surgical assistant can and cannot bill. Meniscus repair is on the list of allowed procedures.
Private Equity Backing for Surgical Assistant Companies
Some of the larger surgical assistant companies are backed by private equity investment. Private equity firms often target segments of the health care system where patients have little choice in who provides their care. Indeed, under anesthesia for surgery, patients are often unaware the assistants are in the operating room. The private equity business models include keeping such helpers out-of-network so they can bill patients for larger amounts than they could negotiate from insurance companies.
Surgical assistants counter that many insurance plans are unwilling to contract with them.
"They're not interested," said Luis Aragon, a Chicago-area surgical assistant and managing director of American Surgical Professionals, a private equity-backed group in Houston.
The University of Michigan recently found that 1 in 5 privately insured patients undergoing surgery by in- network doctors at in-network facilities still receive a surprise out-of-network bill. Of those, 37% are from surgical assistants, tied with anesthesiologists as the most frequent offenders. The researchers found 13% of arthroscopic meniscal repairs resulted in surprise bills, at an average of $1,591 per bill.
Colorado has surprise billing protections for consumers like the Benassos who have state-regulated health plans. But state protections don't apply to the 61% of American workers who have self-funded employer plans. Colorado Consumer Health Initiative, which helps consumers dispute surprise bills, has seen a lot of cases involving surgical assistants, said Adam Fox, director of strategic engagement.
Many report insurance plans simply not paying for surgical assistants, which leaves the patient stuck with the bill.
Patients should ask their surgeons before surgery whether an assistant will be involved and whether that assistant is in-network.
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Study Reviews SARS-CoV-2 Screening Strategies to Permit the Safe Reopening of College Campuses
MyHealthGuide Source: A. David Paltiel, PhD; Amy Zheng, BA; Rochelle P. Walensky, MD, MPH; 7/31/2020, JAMA Network
In this analytic modeling study, screening every 2 days using a rapid, inexpensive, and even poorly sensitive (>70%) test, coupled with strict behavioral interventions to keep Rt less than 2.5, is estimated to maintain a controllable number of COVID-19 infections and permit the safe return of students to campus.
This analytic modeling study included a hypothetical cohort of 4990 students without SARS-CoV-2 infection and 10 with undetected, asymptomatic SARS-CoV-2 infection at the start of the semester. The decision and cost-effectiveness analyses were linked to a compartmental epidemic model to evaluate symptom-based screening and tests of varying frequency (ie, every 1, 2, 3, and 7 days), sensitivity (ie, 70%-99%), specificity (ie, 98%-99.7%), and cost (ie, $10/test-$50/test). Reproductive numbers (Rt) were 1.5, 2.5, and 3.5, defining 3 epidemic scenarios, with additional infections imported via exogenous shocks. The model assumed a symptomatic case fatality risk of 0.05% and a 30% probability that infection would eventually lead to observable COVID-19–defining symptoms in the cohort. Model projections were for an 80-day, abbreviated fall 2020 semester. This study adhered to US government guidance for parameterization data.
The main Outcomes and Measures were cumulative tests, infections, and costs; daily isolation dormitory census; incremental cost-effectiveness; and budget impact.
Study findings
At the start of the semester, the hypothetical cohort of 5000 students included 4990 (99.8%) with no SARS-CoV-2 infection and 10 (0.2%) with SARS-CoV-2 infection. Assuming an Rt of 2.5 and daily screening with 70% sensitivity, a test with 98% specificity yielded 162 cumulative student infections and a mean isolation dormitory daily census of 116, with 21 students (18%) with true-positive results. Screening every 2 days resulted in 243 cumulative infections and a mean daily isolation census of 76, with 28 students (37%) with true-positive results. Screening every 7 days resulted in 1840 cumulative infections and a mean daily isolation census of 121 students, with 108 students (90%) with true-positive results. Across all scenarios, test frequency was more strongly associated with cumulative infection than test sensitivity. This model did not identify symptom-based screening alone as sufficient to contain an outbreak under any of the scenarios we considered. Cost-effectiveness analysis selected screening with a test with 70% sensitivity every 2, 1, or 7 days as the preferred strategy for an Rt of 2.5, 3.5, or 1.5, respectively, implying screening costs of $470, $910, or $120, respectively, per student per semester.
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Legislative News
Third Circuit: Provider’s Out-of-Network Claims not Pre-empted by ERISA
MyHealthGuide Source: Maximilian D. Cadmus & William Gibson, 7/24/2020, Epstein Becker Green via Health Law Advisor
Case: The Plastic Surgery Center, P.A. v. Aetna Life Insurance, No. 18-3381, U.S. 3rd Circuit Court of Appeals. Court's Opinion
The Third Circuit determined in a published opinion that an out-of-network provider’s direct claims against in insurer for breach of contract and promissory estoppel are not pre-empted by ERISA. In the above Surgery case. The Third Circuit addressed the question of what remedies are available to an out- of-network provider when an insurer initially agrees to pay for the provision of out-of-network services, and then breaches that agreement.
This case arose because two patients—identified as J.L. and D.W.—required medical procedures that were not available in-network through Aetna. J.L. needed bilateral breast reconstruction surgery following a double mastectomy and D.W. required “facial reanimation surgery,” which the Third Circuit describes as “a niche procedure performed by only a handful of surgeons in the United States.” Neither J.L. nor DW had out-of-network coverage for these procedures. D.W.’s plan also contained an “anti- assignment” clause, which would have prevented D.W. from assigning his or her rights under the plan to the Plastic Surgery Center, P.A.
Both J.L. and D.W. were referred to the Plastic Surgery Center, P.A., which specializes in plastic and reconstructive surgery. Before agreeing to perform the procedures, the Plastic Surgery Center reached out to Aetna by phone to confirm that Aetna would pay for the treatment.
In both cases, Aetna agreed to pay for the procedures. In J.L.’s case, Aetna approved the breast reconstruction procedure and agreed to pay “a reasonable amount for those services according to the terms of the Plan.” In D.W.’s case, contemporaneous notes record that Aetna agreed to approve the facial surgery and “to provide payment at the ‘highest in-network level.’”
The Plastic Surgery Center performed the required procedures, but Aetna paid only a fraction of its bills. The Plastic Surgery Center filed a lawsuit claiming (1) breach of contract, (2) unjust enrichment, and (3) promissory estoppel.
The district court, in deciding Aetna’s motion to dismiss, held that section 514(a) of the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1001, et seq., which pre-empts state laws that “relate to” ERISA plans, pre-empted all of the Plastic Surgery Center’s claims. Judge Wolfson dismissed the suit in favor of Aetna, and the Plastic Surgery Center appealed.
On appeal, Aetna conceded that a “single stand-alone agreement” between an insurer and out-of- network healthcare practice would not “relate to” an ERISA plan, and therefore would not fall within the ERISA pre-emption language contained in section 514(a). However, Aetna argued that both D.W’s and J.L.’s payment arrangements in this case made reference to the payment terms contained in the Aetna plans, and therefore “relate to” an ERISA plan. Plastic Surgery Center, represented by Maggs McDermott & DiCicco, LLC, argued that that the terms of the plan were not essential to the claims against Aetna, and the Third Circuit agreed.
The panel reasoned that state law claims were not related or connected to the patients’ ERISA benefit plans because the Plastic Surgery Center did not participate in Aetna’s provider network. “Thus, absent a separate agreement between Aetna and the Center, there was no obligation for the center to provide services to the plan participants, no obligation for Aetna to pay the Center for its services, and no agreement that compensation would be limited to benefits covered under the plan.” Therefore, Aetna’s promise to cover the out-of-network procedures fell outside the bounds of the ERISA- covered plan, and was not pre-empted by ERISA.
However, the panel reached the opposite conclusion with respect to the unjust enrichment claim. Whereas a straightforward breach of contract claim or promissory estoppel claim would not require reference to an ERISA plan, the Plastic Surgery Center’s unjust enrichment claim required the Center “to demonstrate that Aetna ‘received a benefit and that retention of that benefit without payment would be unjust.’” The Third Circuit determined that the “benefit” conferred on Aetna was “not the provision of the healthcare services per se, but rather the discharge of the obligation the [Aetna] owes to its insured.” Thus, the unjust enrichment claim could only be satisfied by reference to an ERISA plan and this claim was pre-empted.
Based on this reasoning, the Third Circuit affirmed the dismissal of the Plastic Surgery Center’s unjust enrichment claim, but reversed the dismissal with respect to the Center’s breach of contract and promissory estoppel.
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Medical News
Antibiotic Therapy has 61% Success Rate vs Laparoscopic Appendectomy Among Children With Uncomplicated Appendicitis
MyHealthGuide Source: Peter C Minneci, MD, MHSc, et. al, 7/27/2020, JAMA Network
Among children with uncomplicated appendicitis, an initial nonoperative management strategy with antibiotics alone had a success rate of 67.1% and, compared with urgent surgery, was associated with statistically significantly fewer disability days at 1 year.
This multi-institutional nonrandomized controlled intervention study of 1068 children aged 7 through 17 years with uncomplicated appendicitis treated at 10 tertiary children's hospitals across 7 US states between May 2015 and October 2018 with 1-year follow-up through October 2019. Of the 1209 eligible patients approached, 1068 enrolled in the study.
Patient and family selection of nonoperative management with antibiotics alone (nonoperative group, n = 370) or urgent (≤12 hours of admission) laparoscopic appendectomy (surgery group, n = 698).
The 2 primary outcomes assessed at 1 year were disability days, defined as the total number of days the child was not able to participate in all of his/her normal activities secondary to appendicitis-related care (expected difference, 5 days), and success rate of nonoperative management, defined as the proportion of patients initially managed nonoperatively who did not undergo appendectomy by 1 year (lowest acceptable success rate, ≥70%). Inverse probability of treatment weighting (IPTW) was used to adjust for differences between treatment groups for all outcome assessments.
Study findings
Among 1068 patients who were enrolled (median age, 12.4 years; 38% girls), 370 (35%) chose nonoperative management and 698 (65%) chose surgery. A total of 806 (75%) had complete follow-up: 284 (77%) in the nonoperative group; 522 (75%) in the surgery group. Patients in the nonoperative group were more often younger (median age, 12.3 years vs 12.5 years), Black (9.6% vs 4.9%) or other race (14.6% vs 8.7%), had caregivers with a bachelor's degree (29.8% vs 23.5%), and underwent diagnostic ultrasound (79.7% vs 74.5%). After IPTW, the success rate of nonoperative management at 1 year was 67.1% (96% CI, 61.5%-72.31%; P = .86). Nonoperative management was associated with significantly fewer patient disability days at 1 year than did surgery (adjusted mean, 6.6 vs 10.9 days; mean difference, -4.3 days (99% CI, -6.17 to -2.43; P < .001). Of 16 other prespecified secondary end points, 10 showed no significant difference.
However, there was substantial loss to follow-up, the comparison with the prespecified threshold for an acceptable success rate of nonoperative management was not statistically significant, and the hypothesized difference in disability days was not met.
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Recurring Resources
Medical Stop-Loss Providers Ranked by 2019 Annual Premium Tops $23 Billion
Source: MyHealthGuide, 5/23/2020
The Medical Stop-Loss Provider Ranking has been updated based on 2019 Annual Premium. In addition, Rankings from years 2018, 2017 and 2016 have been incorporated into a single table.
The top 96 stop loss providers are ranked. The Medical Stop-Loss Provider Ranking table data reflect Direct Earned Premium from the "Accident and Health Policy Experience Exhibit" ("Supplemental Pages, Insurance Expense Exhibit” section) of publicly available Statutory Reports filed annually by each insurance carrier. Click here to view The Medical Stop-Loss Provider Ranking
Stop Loss Premium Growth
Stop Loss premium based on 2019 annual premium is $23,588,932 (thousands), a 57% over 2016 annual premium of $15,004,224 (thousands) for a compounded annual rate of 16.2%. Stop Loss premium totals by year:
2019 - $23,588,932 (thousands) 2018 - $19,849,233 2017 - $16,451,079 2016 - $15,004,224
Top 20 and Ranking Changes
The top 20 stop loss providers based on 2019 annual premium:
1. Cigna 2. CVS Health Corp (includes Aetna acquisition) 3. UnitedHealth Group 4. Sun Life Financial 5. Anthem 6. Tokio Marine HCC 7. Voya Financial Inc. 8. HCSC 9. Symetra 10. HM Insurance 11. Humana 12. Companion Life/Blue Cross Blue Shield of SC 13. Swiss Re 14. W. R. Berkley Corp. 15. Western & Southern Financial 16. Fairfax Financial (CF Ins) 17. Blue Cross Blue Shield of MI 18. QBE 19. Nationwide 20. National General Holdings Corp
In the new updated 2019 ranking, there were
14 providers that did not change their ranking position from 2018. 41 providers moved up in the ranking. 26 providers moved down in the ranking. 12 providers are new the ranking.
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Upcoming Conferences
September 14-17, 2020 - Virtual Meeting SPBA Fall Meeting (members only). Society of Professional Benefit Administrators (SPBA) www.SPBATPA.org
September 21-23, 20200 Benefits Forum & Expo. The coronavirus crisis and its aftermath will impact the evolution of benefits and workplace culture. Connections are deeper when people are able to share space while also sharing thoughts, ideas, insights and values. With this in mind, we are proceeding as planned in hosting our annual Benefits Forum & Expo conference. Austin, TX. Register online or call Ryan Fallon at (212) 803- 8817 or Frank Fiorino at (212) 803-8832.
September 23-25, 2020 - Virtual Event Creating and Expanding Worksite Health Centers –8th Annual NAWHC Forum presented by National Association of Worksite Health Centers. The 2020 NAWHC Annual Forum is now a virtual program, spread over three days, with no more than four hours of sessions each day. It is designed to allow you to customize your experience to meet your needs, time frame, comfort and areas of interest. You can participate in the entire three days or focus only those sessions of greatest priorities for just one small fee. As a virtual event, you don’t have to travel or be concerned about exposure to others in a large event venue. This will be one of the few opportunities this year for you to hear from leading employers and national experts on the direction of worksite centers, new center strategies, issues and services. See the Agenda. Chicago. Information and Registration.
October 5-8, 202020 WLT Software Client Conference 2020. Clearwater Beach Marriott Suites on Sand Key, Clearwater, Florida. Contact Joe Torina, Marketing Director / Business Partner Development, WLT, at [email protected].
October 11-13, 2020 National Conference & Expo presented by Self-Insurance Institute of America. JW Marriott Desert Ridge Resort & Spa. Phoenix, AZ. Registration will be open in April. Information & Registration.
December 9, 2020 Best Practices in Treating MSK and Back Pain in Your Worksite Clinic presented by National Association of Worksite Health Centers. Musculoskeletal conditions and pain management are top clinical problems for employers and their health centers. To address this, a special targeted event will provide the latest research, best practices and experiences in treating these conditions with traditional and alternative approaches. If the COVID-19 situation still impacts in-person meetings, we will move this to a virtual event. Dallas, TX. Information and Registration.
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January 28-29, 2021 2021 Onsite Employee Health Clinics Summit presented by National Association of Worksite Health Centers. This conference, produced by NAWHC partner World Conference Forum, offers two days of learning, networking and exhibits. . NAWHC members receive a $250 discount off the registration fees by using "NAW250" as the "keycode" Phoenix, AZ. Information and Registration.
February 8-10, 2021 HCAA's s Executive Forum 2021 presented by Health Care Administrators Association, Bellagio, Las Vegas, NV. Information
July 19-20, 2021 HCAA's TPA Summit 2021 presented by Health Care Administrators Association, Hyatt Regency, Dallas, TX. Information
October 3-5, 2021 National Conference & Expo presented by Self-Insurance Institute of America. Austin, TX.
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February 21-23, 2022 HCAA's Executive Forum 2022 presented by Health Care Administrators Association, Bellagio, Las Vegas, NV. Information
July 18-19, 2022 HCAA's TPA Summit 2022 presented by Health Care Administrators Association, Hyatt Regency St. Louis at The Arch, St. Louis, MO. Information
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July 17-18, 2023 HCAA's TPA Summit 2023 presented by Health Care Administrators Association. Hyatt Regency, Dallas, TX. Information
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Job News (Listings are generally published for 1 month)
Berkley Accident and Health Seeks a Group Captive Program Manager Responsibilities
MyHealthGuide Source: Berkley Accident and Health, 8/3/2020
The Captive Program Manager develops and manages trusted relationships with assigned captive programs, functioning as primary liaison, supporting the implementation of new programs and delivering reporting, analysis and making recommendations of best practices and health risk management approaches to mitigate financial exposure.
Locations Flexible, but ideally working from offices in New Jersey, New York, Pennsylvania, or Connecticut.
Duties and responsibilities include, but are not limited to:
Developing and managing trusted relationships with assigned captive programs, including effectively interfacing with C-Suite and executive level business relationships at the policyholder, TPA, Broker, Captive and a variety of third parties. Functioning as primary liaison with Captive Manager and overseeing necessary captive deliverables to ensure timely cession reporting and member/consultant support. Coordinating and preparing monthly, quarterly and annual loss reporting packages, quarterly conference calls, and 1:1 report introduction calls, as well as supporting and presenting at regional and annual program meetings Developing and managing communication of results and performance of assigned captive programs to internal and external parties, including analysis of historical performance and interpretation of loss performance. Developing and managing surveys and voting for assigned captive programs. Working with distribution channel and captive members in development and implementation of risk management strategies and education of potential health risk management solutions/vendors. Supporting the launch of new captive programs including establishing the cession reporting, coordinating calls and logistics with Program Sponsor/Captive Manager to ensure a smooth implementation. Developing documentation/recommendation of processes and procedures to support efficiency and growth targets for the captive division. Effectively liaising with various operating areas including premium accounting, finance, and clinical team on behalf of policyholders and consultant brokers to ensure understanding of claims handling, premium processes, policy provisions/endorsements and understanding internal health risk management services. Managing vendor relationships to maintain smooth coordination between the parties (TPAs, disease management, broker, captive, members, etc.) In collaboration with AVP, overseeing the activities of account management team assigned to programs, including training, development, and input on performance reviews to ensure appropriate coordination of information and resources to achieve customer service standards. At times providing back-up and support in interfacing with broker, policyholder and TPAs.
Qualifications
BA/BS degree in related field of study ideal 5+ years of experience in the Group Employee Benefits with deep understanding of and exposure to Health insurance plans that include Self Funding and Stop Loss, in the Brokerage, Consulting or Carrier aspects of the insurance industry. Professional designations such as CEBS or GBA helpful but not required Calm under pressure. You have excellent organizational skills, integrity, and great follow- through on tasks. You are comfortable challenging norms while working collaboratively with colleagues at all levels of the organization Exceptional communication skills. Your communication style is flexible to the situation and audience. You communicate clearly and with a purpose both one on one and in front of larger groups Strong business acumen, mathematic fluency and financial analysis skills required Must be able to travel as needed and up to 35%
To apply for this job, please visit: https://careers-berkley.icims.com/jobs/4005/program-manager%2c- captives/job
About Berkley Accident and Health
We help companies and organizations better manage their financial risk arising from catastrophic health events. We protect companies with four types of business insurance: Employer Stop Loss, Group Captives, Managed Care, and Specialty Accident. Our insurance products are underwritten by Berkley Life and Health Insurance Company, rated A+ (Superior) by A.M. Best and selected as a Ward’s 50 top- performing insurer for safety and consistency.
Berkley Accident and Health is a Berkley Company and part of W. R. Berkley Corporation, a Fortune 500® company and a member of Forbes’ America’s Best Employers list. Berkley Accident and Health has primary offices in Hamilton Square, NJ and Marlborough, MA and satellite offices nationwide. Visit www.BerkleyAH.com.
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CWI Benefits in Greenville, SC Seeks Vice President of Operations
MyHealthGuide Source: CWI Benefits in Greenville, 7/27/2020
CWI Benefits in Greenville, SC seeks a Vice President of Operations with Health Insurance industry experience.
This role which is located in the heart of Greenville in our corporate office is responsible for the overall direction, coordination and evaluation of the Claims and Customer Service areas. Involves “hands-on” daily interaction with Customer Service Agents, CSA Supervisor, Claims Manager and Claims Agents, and other relevant departments. Recommends and implements initiatives to improve department efficiency, productivity, workflows, and costs. Responsible for delivery of quality service to members and providers that exceeds customers’ expectations, Company standards and contract obligations. Reports to the President.
MUST HAVE THE BELOW MINIMUM QUALIFICATIONS TO BE CONSIDERED FOR THIS POSITION:
Bachelor’s degree in a business-related subject or equivalent experience. At least 5 years Claims and Customer Service supervisory experience managing and training a large Claims and Customer Service unit with a healthcare payer, delegated vendor, or TPA, supervising a team of agents. Strong performance management and productivity optimization skills, including reporting, analysis and recommendations. Strong technology background interfacing with IT personnel. Working knowledge of current commercial health insurance product options, including HMO, PPO, EPO, high deductible plans, copay/coinsurance variations, and HRA’s/HSA’s. Expertise in claims adjudication, including interface with payers with or without delegation, eligibility and benefit determination, and member copay/coinsurance allowances. Working knowledge of electronic commerce for providers and members. Thorough HIPAA knowledge.
ESSENTIAL FUNCTIONS
Plans, organizes and manages Customer Service and Claims functions. Coaches team leaders/supervisors/area managers in the supervision of Claims/Customer Service Agent activities. Drives performance by ensuring all employees are trained, and work is completed in accurate timely manner and meets company and contract standards. Monitors and tracks individual, team and call center performance against established productivity and quality metrics, including regular audits assessing department performance. Identifies and acts on both positive and negative performance trends to ensure attainment of goals. Monitors phone calls to observe agent demeanor, technical accuracy, and conformity to HIPAA, URAC and Company standards. Addresses agent performance as needed. Monitors work queues, prioritizes incoming authorizations and effectively delegates tasks to team leaders/supervisors/area managers to ensure company standards and contract obligations are met. Handles complex customer issues escalated by agents, supervisors and team leads. Coaches Agents, supervisors/team leads, and managers in troubleshooting routine as well as difficult customer issues. Participates in daily, weekly and ad hoc cross-functional meetings to discuss and resolve operational and technical issues. Oversees day-to-day claims operations, including claims evaluation, adjudication and customer service in accordance with contract and Company quality and production standards. Reviews Claim audits for completeness, accuracy of information and compliance with WIN’s policies, standards and procedures. Resolves any issues or directs claim to team lead/area manager for resolution prior to payment. Conducts regular Customer Service Agent audits to ensure accuracy and timeliness consistent with company and or client standards. Recommends changes to workflow, procedures or policies and ensures that all Customer Service and Claims employees are fully informed, understand and implement changes. Identifies leads, develops and organizes training, re-training and cross-training of team members and new employees as appropriate and in coordination with Managers. Prepares and presents a variety of management reports, including explanation of variances, significant trends, and recommendations for change or resolution. Keeps other Vice Presidents and President adequately informed of department issues, trends, challenges, and problem identification/resolution. Ensures service compliance with client performance guarantees, and regulatory or accreditation standards. Participates in sales presentations, demonstrations, and new client implementations as needed, to ensure smooth and timely transition of new business. Follows and ensures team follows HIPAA and URAC protocols when discussing or accessing protected health information.
SUPERVISORY RESPONSIBILITIES
Responsible for direct supervision of Managers, Team Leaders, Supervisors, and as needed Claims and Customer Service Agents. Carries out supervisory responsibilities in accordance with Company policies and applicable laws. Responsibilities including interviewing, participating in hiring decisions and training employees; planning, assigning, and directing work; appraising performance; addressing and resolving problems.
BENEFITS
WIN offers our employees competitive and comprehensive benefits to include but not limited to:
Paid vacation and holiday time Medical Dental Vision Life Insurance Disability Insurance 401k plus company match
Job Type: Full-time
CWIBenefits LLC is in growth mode to allow for this opportunity.
Interested candidates should send resume to Jason Kelley, VP, at jason.kelley@cwibenefits.com.
About CWIBenefits LLC (CWI)
CWIBenefits LLC (CWI), is a technology based Third Party Administrator (TPA), offering total benefits administration services and data management. We offer turnkey online enrollment, billing, claims and call center operations to help you meet your benefit solutions strategies and needs so you can grow your business and attentively serve your membership.
Implementation & integration is seamless, as we bring 30 years of expertise & technology to your clients. As the trusted service and benefits technology platform of Employers, Health Plans, and Benefits Administrators, CWI has evolved to be a TPA, data integrator, and Software-as-a-Service vendor. Visit cwibenefits.com.
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Professional Benefit Administrators, Inc. (PBA) Seeks Claims Manager
MyHealthGuide Source: Professional Benefit Administrators, Inc. (PBA), 7/20/2020
Position: Medical Claims Manager Location: Oak Brook, IL or remote if outside the Chicagoland area
Company Overview: PBA is one of the leading independent third-party administrators in the industry. We consider ourselves to be in the people business, and in this time of change, we reaffirm our commitment to maintaining the satisfaction of our customers as well as building and maintaining strong relationships with our clients and partners alike. Our leadership team is engaged, evolving and eager to make a difference in the industry.
Responsibilities include: Leading Claims Supervisors and Claims Staff, coaching and developing claims team, responding to questions posed by direct reports and other staff members, evaluating ongoing training needs, and reporting department activity to the Director of Operations.
Skills needed: Minimum of 3-5 years’ experience in Claims leadership, strong claim knowledge/understanding as well as solid presentation/communication/decision-making skills, experience with stop loss/reinsurance, effectively deal with challenges, and ability to interface with all levels of the organization.
Interested candidates should e-mail their resume to [email protected].
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Berkshire Hathaway Specialty Insurance Company Seeks Experienced Senior Underwriter
MyHealthGuide Source: Berkshire Hathaway Specialty Insurance Company (BHSI), 7/20/2020
Are You an Experienced Senior Stop Loss Underwriter?
Interested in: Working for an ever-growing international company where your values matter, where you are asked to do the right thing for the right reason. If being part of a supportive team, where your contribution is appreciated and acknowledged, where “Simplicity of Complexity” is one of our guiding principles, then we are waiting for you to join us, as we continue to build a “Forever Company”
Then check out this opportunity at BHSI: https://bhspecialty.com/career/senior-stop-loss-underwriter/
Position Overview
Berkshire Hathaway Specialty Insurance Company (BHSI) is seeking an experienced Senior Underwriter for their growing medical stop loss unit. The Senior Underwriter will support his/her distribution partner in developing and expanding customer, broker, and external partner relationships. The Senior Underwriter will partner with our stop loss sales team to build a book of business through achieving new business sales and renewals.
We are seeking candidates who have 8+ years of medical stop loss underwriting experience, thrive in an entrepreneurial and collaborative environment, and exhibit a thorough understanding of the principals of stop loss underwriting.
Essential Job Functions
Partnering with distribution, builds and manages a profitable book of business with emphasis on new business sales, renewal persistency, and loss ratio targets Underwrite assigned accounts in an expedient manner, while ensuring quality decision making, rating accuracy, appropriate analysis and documentation Analyze customer characteristics including demographics, evaluate plan documents, assess claims experience and ensure proper pricing by following underwriting policies and established methodologies Evaluate clients proposed benefit plan design and funding method Develop and maintain strong relationships with BHSI Stop Loss Sales Representatives, Producers and Policyholders by providing additional information, clarity, and obtaining risk related information on which to base decisions Negotiate pricing, plan options and reimbursement arrangements Provide training and guidance to Sales team, brokers, internal team members and external partners Participate in Stop Loss product development and enhancements
Requirements
8+ years of medical stop loss underwriting experience Extensive medical stop loss product and market knowledge Strong underwriting acumen Customer focused Analytical skills and research abilities Advanced negotiation skills Excellent interpersonal and communication skills Passionate and professional demeanor that supports a collaborative and team-oriented environment; strong personal ethics a must Experience with ESLOffice desirable BA/BS degree or equivalent experience
About Berkshire Hathaway Specialty Insurance (BHSI)
A strong, trusted insurance partner, Berkshire Hathaway Specialty Insurance (BHSI) provides a broad range of commercial property, casualty and specialty insurance coverages and outstanding service to customers around the globe. Part of Berkshire Hathaway’s insurance operations, we bring our solutions to market with our stellar brand name, top-rated balance sheet, and the expertise of our global team of professionals with excellent capabilities and character. Want to be part of the team building the finest property, casualty and specialty lines insurance company in the world? Visit bhspecialty.com. Top
HM Insurance Group Seeks Senior Medical Stop Loss Underwriter
MyHealthGuide Source: HM Insurance Group, 7/13/2020
Position: Senior Medical Stop Loss Underwriter Location: Remote
Company Overview
With more than 35 years in the Stop Loss insurance market, HM Insurance Group works to deliver smart solutions, exceptional performance and unparalleled support. Learn more here.
General Overview
This job prices quotes and analyzes the structure of a contract for a group based on claims experience, characteristics of the employee groups, etc. The incumbent uses discretion of Underwriting authority within the policies of HMIG and ensures appropriate levels of profitability and growth over time. Identifying when to decline quotes that do not fit into the overall HMIG strategy and risk structure. Analyzes risk factors for new enrollment, annual renewals, and amendments of group insurance contracts or of self-funded plans in conformance with established underwriting policies, practices, and standards. Analyzes associated policies, guidelines, market data to continuously improve risk management and gain appropriate enrollment or manage existing membership. Analyzes data such as financial conditions of the organization, participation percentage, type of industry, characteristics of employee groups, or past claim experience to determine what benefits can be offered and to set the rates. Prepares a variety of reports and provides rationale and support to other areas within the organization, clients, and possibly producers regarding one or more of the following: underwriting results, rate computations and financial activity. Provides expense estimates and accurate analysis of financial exhibits. The incumbent provides oversight, guidance and/or assistance to lower level HMIG Underwriters.
How to Apply
Those interested can review the full posting and apply directly here.
About HM Insurance Group
HM Insurance Group (HM) works to protect businesses from the potential financial risk associated with catastrophic health care costs. The company provides reinsurance solutions that address risk situations confronting employers, providers and payers. A recognized leader in employer stop loss, HM also offers managed care reinsurance nationally. Through its insurance companies, HM Insurance Group holds insurance licenses in 50 states and the District of Columbia and maintains sales offices across the country. Visit hmig.com.
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FullscopeRMS Seeks Two Positions
MyHealthGuide Source: FullscopeRMS, 7/13/2020
The FullscopeRMS (an affiliate of Sun Life) team is expanding and looking to add the following positions to help support our continued strong growth.
Business Development Executive - Healthcare
Click here full details.
Associate Director, Implementation and Client Manager
Click here full details.
About FullscopeRMS
FullscopeRMS delivers risk management expertise, performance and brand protection to partners in the insurance industry by helping them bring new products to market and expanding their current business. FullscopeRMS provides its clients – including 25+ insurance carriers and health plans –with the deep knowledge, expert talent and the specialized systems required to offer full disability, absence management, life, stop-loss, and supplemental health to employers. FullscopeRMS is a standalone company in the Sun Life U.S. group of businesses. Visit www.fullscoperms.com.
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The Phia Group Open Positions
MyHealthGuide Source: The Phia Group, 7/13/2019
The Phia Group has a variety of open positions that can be viewed by clicking here. Contact us at [email protected] for employment questions.
About The Phia Group
The Phia Group, LLC, headquartered in Canton, Massachusetts, is an experienced provider of health care cost containment techniques offering comprehensive claims recovery, plan document and consulting services designed to control health care costs and protect plan assets. By providing industry leading consultation, plan drafting, subrogation and other cost containment solutions, The Phia Group is truly Empowering Plans. Visit www.PhiaGroup.com.
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MSL Captive Solutions Seeks Senior Underwriting Specialist and Senior Administrative Specialist
MyHealthGuide Source: MSL Captive Solutions, Inc., 7/6/2020
MSL Captive Solutions, Inc. has openings for a Senior Underwriting Specialist and a Senior Administrative Specialist to join its new venture focusing exclusively on captives. These positions will help lead and manage the underwriting operations as we seek to grow in an emerging, exciting segment of the medical stop loss market.
Interested candidates should send cover and resume to [email protected].
About MSL Captive Solutions, Inc.
MSL Captive Solutions, Inc. is a specialist underwriting and consulting services firm focused on the use of captives in medical stop loss programs. The independent new entity will work closely with brokers, consultants and all captive managers to structure customized single-parent and group captive solutions to meet the specific risk and financial objectives of their clients. Visit www.mslcaptives.com.
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Editorial Notes, Disclaimers & Disclosures
Articles are edited for length and clarity. Articles are selected based on relevance and diversity. No content in this Newsletter should be construed as legal advice. All legal questions should be directed to your own personal or corporate legal resource. Internet links are tested at the time of publication. However, links change or expire often. Articles do not necessarily reflect views held by the Publisher. Should you stop receiving the Newsletter, here are some items to check: Is the Newsletter email in your junk or spam folder? • Have your IT team "whitelist" sender ([email protected]) • Provide another email address. • Access the Newsletter online at www.MyHealthGuide.com/news.htm.
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Ernie Clevenger President & Publisher MyHealthGuide, LLC [email protected]